Introduction: Problems of Poor Adherence

SIGNIFICANCE FOR THE PRACTICING PSYCHIATRIST

The World Health Organization defines adherence as “the extent to which a person’s behavior-taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care professional.” Suboptimal adherence is pervasive among individuals with chronic health conditions, including psychiatric disorders, and nearly always contributes to worse outcomes.

Much time, effort, and resources have been devoted to developing psychotropic drugs that are safe and effective, and that improve health outcomes. However, drugs don’t work if patients don’t take them. Rates of poor adherence can exceed 60% among patients with schizophrenia. Moreover, poor adherence is associated with relapse, hospitalizations, and high financial costs. Among patients with bipolar disorder, rates of nonadherence are estimated at 20% to 60%, and they are similarly associated with more relapse, higher costs and, in worst-case scenarios, suicide.

Approximately 30% of patients stop taking antidepressants after 1 month and 45% to 60% after 3 months. Poor adherence to evidence-based medication treatment is a problem that crosses psychiatric diagnoses and types of psychotropic medications. Fortunately, an emerging literature on the topic of adherence enhancement provides input on how clinicians might address adherence with their patients.

The articles in this 2-part Special Report spotlight the issue of poor adherence, particularly medication adherence, and take on some of the multiple areas where interventions may be possible. In part 1, one article focuses on psychotherapy tools to improve adherence. A key emphasis is that changing adherence is a process that takes time and effort to master. The other article addresses the importance of culture as a factor in adherence. Effective adherence enhancement is never “one size fits all,” and culture-specific factors need to be targeted to move the adherence dial.

Related content.

Treatment Adherence: Strategies and Best Practices

In part 2, coming in the September issue, one article addresses incentives for adherence-an approach that appears effective in other health conditions and may also translate to psychiatric disorders. While one might argue that good health is its own “reward,” compensating individuals for positive health behaviors is likely to be a win-win situation for patients, payers, and care systems. The issue of motivation as it affects medication adherence is the focus of another article. The final article focuses on the benefits of partnering with primary care providers. Collaborative care can be an effective way to target suboptimal adherence, particularly given the multi-morbidities experienced by many patients with mental health disorders.

MORE ABOUT Martha Sajatovic, MD

[[{"type":"media","view_mode":"media_crop","fid":"61963","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_4344494926623","media_crop_h":"300","media_crop_image_style":"-1","media_crop_instance":"7846","media_crop_rotate":"0","media_crop_scale_h":"149","media_crop_scale_w":"125","media_crop_w":"252","media_crop_x":"33","media_crop_y":"0","style":"font-size: 13.008px; float: right;","title":" ","typeof":"foaf:Image"}}]]I am a Professor of Psychiatry and of Neurology at Case Western Reserve University School of Medicine in Cleveland, Ohio. I am a researcher, educator, and clinician and have devoted myself to the study and treatment of traditionally hard-to-treat populations with CNS disorders for the past 3 decades.

Relevant to the topic of the Special Report on treatment adherence in this issue, my interest in adherence began in 2003, when I was the recipient of a National Institute of Mental Health career development research grant (K-award). The K-award allowed me to focus on this topic and learn research methods, including those borrowed from the field of medical anthropology. Approaching the topic of suboptimal treatment adherence from the perspective of a person with a health condition can be an important way to understand adherence behavior.

Understanding why a person does or does not take medication is valuable in being able to apply methods of intervention that consider benefits versus burdens of treatment. In addition, the K-award mechanism is a wonderful opportunity to learn new skills that can make one a better and more competitive researcher. Collaborations and relationships that were established during my own K-award definitely amped up my grant-writing skills by orders of magnitude!

Since 2009, I have had an academic appointment in the Department of Neurology at University Hospitals of Cleveland and have been conducting research in brain disorders that affect behavior, such as epilepsy, stroke, and dementia. I run a health services center called the Neurological and Behavioral Outcomes Center. This has allowed me to interact with a whole new range of colleagues and reminds me how very closely the disciplines of psychiatry and neurology are intertwined. More recently, I have been involved in global brain health research with colleagues in Uganda and in Tanzania.

Disclosures:

Dr. Sajatovic is Professor of Psychiatry and of Neurology at the Case Western Reserve University School of Medicine, University Hospitals Case Medical Center in Cleveland, OH.

Dr. Sajatovic reports no conflicts of interest concerning the subject matter of this Special Report.